Continuous blood glucose monitoring and characteristics of diabetes in patients on maintenance haemodialysis treatment

Continuous interstitial glucose monitoring in non-diabetic subjects with end-stage renal disease undergoing maintenance haemodialysis

Haemodialysis improves uraemia-induced insulin sensitivity and is therefore likely to induce significant changes in circulating glucose concentrations in end-stage renal disease (ESRD). We aimed to assess clinically relevant circulating glucose changes in patients undergoing chronic maintenance haemodialysis using continuous interstitial monitoring. We investigated 14 non-diabetic ESRD subjects aged 40.6+/-2.4 years. Participants were examined 24-h day pre-dialysis, during the index dialysis session and 24-h post-dialysis with simultaneous measurement of capillary blood glucose and continuous interstitial glucose (CGMS). Participants performed five capillary blood glucose measurements the day before dialysis, and 10 during and after dialysis. Mean capillary blood glucose was 128+/-20mg/dl the day before, 93+/-8mg/dl during haemodialysis, and 105+/-13mg/dl after haemodialysis. There was a significant trend towards lower blood glucose during the session from 105+/-16mg/dl to a 3rd hour nadir of 83+/-15mg/dl (Anova F=2.89, p=0.029). No hypoglycaemia was recorded. Interstitial glucose profile was comparable to capillary glucose profile. Glucose concentrations varied significantly from 126+/-13mg/dl before to 112+/-12mg/dl after haemodialysis respectively (p=0.006). This study provides evidence for the use of CGMS in ESRD and haemodialysis, and demonstrates significant changes in glucose concentrations during and after haemodialysis that would guide treatment monitoring and adjustments.

Glycaemic control in type 2 diabetic patients on chronic haemodialysis: use of a continuous glucose monitoring system

BACKGROUND

The proportion of diabetic patients undergoing haemodialysis is rapidly increasing. Glucose control among such patients is difficult to assess. We aimed to evaluate the clinical performance of a continuous glucose monitoring system (CGMS) in type 2 diabetic patients on chronic haemodialysis.

METHODS

We used a 4-day CGMS to monitor glucose levels in 19 haemodialysed type 2 diabetic patients (HD T2) including 2 days with and 2 days without dialysis session, and 39 non-HD T2 in a double-centre study.

RESULTS

The glucose concentration according to the glucose meter and CGMS were correlated in HD T2 patients (r = 0.90, P < 0.0001) and in non-HD T2 patients (r = 0.81, P < 0.0001). The relative absolute difference (RAD) between glucose determined by a glucose meter and glucose determined by the CGMS did not differ between HD T2 and non-HD T2 patients (9.2 +/- 10.5 vs. 8.2 +/- 7.6%; P = 0.165). Glycated haemoglobin (A1c) and mean glucose concentration were strongly correlated in non-HD T2 patients (r = 0.71; P < 0.0001) but weakly correlated in HD T2 patients (r = 0.47; P = 0.042). Fructosamine was correlated with the mean glucose concentration in non-HD T2 (r = 0.67; P < 0.0001) but not in HD T2 patients (r = 0.04; P = 0.88).

CONCLUSION

CGM is a validated marker of glycaemic control in HD diabetic patients. This tool showed that A1c and fructosamine, despite being good markers of glycaemic control in non-HD diabetic patients, are of poor value in HD diabetic patients.

Hospital hypoglycemia: not only treatment but also prevention

OBJECTIVE

To propose a strategy, applicable on general hospital wards, for prevention of hypoglycemia in hospitalized patients.

RESULTS

Although the mortality rate among hospitalized patients with hypoglycemia has been shown to be 22.2 to 27% in series that included patients with diabetes, some investigators have shown that hypoglycemia is not an independent predictor of mortality. Outside the critical care setting, the comparative risks of hyperglycemia and hypoglycemia and the relationship of hospital hypoglycemia to intensification of glycemic control have not been determined. The reported incidence of hospital hypoglycemia ranges from 1.2% for hospitalized adults to 20% for nonpregnant patients with diabetes admitted without a metabolic emergency. Among patients receiving antihyperglycemic therapy, the literature describes precipitating events--usually a sudden change of caloric exposure-- and predisposing conditions for hypoglycemic episodes.

CONCLUSION

Hospital hypoglycemia is predictable, and it is preventable by measures other than undertreatment of hyperglycemia. Physician orders for antihyperglycemic therapy should be written and, if necessary, be revised so as to respond to the presence of predisposing conditions for hypoglycemia. A ward-based protocol or hospital-wide policy should establish the appropriate response to triggering events. Within the time frame of action of previously administered antihyperglycemic drugs (after abrupt interruption of caloric exposure), the threshold for preventive intravenous administration of dextrose is a glucose concentration of 120 mg/dL.